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What do they do?
The NFP model consists of having trained registered nurses visit low-income, first-time mothers—starting with weekly visits early in pregnancy, and progressing toward monthly visits until the child's second birthday—attempting to help with prenatal health (nutrition; obtaining prenatal care; and reducing alcohol, tobacco, and drug use during pregnancy), child care, and personal life management (planning future pregnancies and taking steps toward education and employment).
The Nurse-Family Partnership (NFP) primarily provides a consulting (as opposed to funding or implementing) role, partnering with regional organizations to carry out the NFP program. We present below NFP's activities, along with the associated 2009 expenses (which we cite below as a proportion of the organization's total expenses):
- Program development (22%): helping regional organizations raise funding and preparing them to deliver NFP services.
- Nursing practice (16%): training and supporting participating nurses.
- Program quality support (16%): ongoing evaluation and consultation with regional programs.
- Federal policy and program finance (7%): advocacy for more government funding of NFP programs.
- Other (40%): administrative and management costs; information technologies; marketing; program research; and a small amount for grants to Colorado NFP agencies.
Does it work?
Evidence of impact
The NFP program has been rigorously evaluated in three studies that found positive, long-term impacts, including less child abuse and neglect, and fewer arrests and convictions. For more on evidence of effectiveness, see our review of the Nurse-Family Partnership program
There is reason for caution in extrapolating from the results of these studies to the expected impact of the NFP program as a whole; the question is how well regional programs, working with NFP's help, can replicate the most important aspects of the program. We cannot be fully confident about the quality of replication, but are cautiously optimistic for the following reasons:
- NFP was established with direct involvement from David Olds, the lead researcher on all of the above studies, specifically to replicate the program under discussion.
- NFP has clear, measurable criteria for adherence to the program, including the requirement that registered nurses carry out the program according to the (proprietary) NFP curriculum.
- As shown in the rigorous studies of the NFP program, empirical evidence for the model's effectiveness holds across very different populations.
- NFP appears thorough in its ongoing monitoring of its work and the monitoring results we have considered are consistent with positive impact (more on this in the next section).
The Nurse-Family Partnership monitors outcomes for all clients to determine whether the program is achieving expected results. The Nurse-Family Partnership sent us detailed reports which provide data, including the following indicators (all of which were measured in the earlier, randomized controlled trials):
- Maternal smoking during pregnancy
- Time between a mother's current pregnancy and her next pregnancy
- Maternal self-sufficiency (as measured by mothers' workforce participation level)
The trends presented in the reports are consistent with the Nurse-Family Partnership having a positive impact:
- Between intake and the 36th week of pregnancy, self-reported cigarette smoking fell from 14.4% to 12.1% of mothers; drug use from 1.4% to .5%; and, alcohol use from 1.3% to .9%.
- At intake, 6.1% of mothers reported experiencing physical abuse from her partner; at 36 weeks, only 3.6% reported experiencing physical abuse.
While we have not analyzed the results in the monitoring reports to determine whether the results the Nurse-Family Partnership is currently achieving are consistent with the trial results, we commend them for their ongoing monitoring of their work and believe that the results we have considered are consistent with a positive impact.
What do you get for your dollar?
According to NFP, the cost to a community/agency is typically $4,500 per family per year served in the NFP program, and ranges from $2,914 to $6,463 per family per year. These figures imply a typical cost of $10,800 per family served in the NFP program. We don't know how NFP came to the cost figures above and what costs they include to what actors.
According to The Coalition for Evidence-Based Policy, the program costs around $12,500 per woman over the approximately 3 years of visits.
Room for more funds?
We feel that NFP has room for more funding only over the long term, and that potential donors should take this into account.
Details: In 2007, NFP launched a campaign to raise money so that NFP could become, over a ten-year period, self-sustaining on the fees it collects from local NFP programs. In 2007, NFP successfully got commitments of approximately $50 million for this purpose, the full amount it sought.
Since then, NFP has revised its cash flow projections, making the projections less optimistic in light of the weak economy. It has shared these cash flow projections for our eyes only. The projections anticipate that donations will be needed for several years to cover the gap between earned revenues (from local NFP programs) and expenses, and that it will take until 2021 to get to the point where earned revenues cover 98% of all expenses.
From these projections, it appears to us that existing commitments can sustain NFP through 2015, at which point the organization will likely need more donations in order to continue operating. It also seems likely to us that any additional donations in the meantime will be essentially “held for a rainy day,” i.e., saved for the point at which they are needed to cover this gap. Because NFP’s goal is to become self-sustaining on earned revenue, it seems unlikely that it would use more donations to directly increase the reach of its program (e.g., through providing its services to local NFP offices for free or reduced prices).
We feel that NFP is an outstanding organization, with a stronger case for its effectiveness than any other organization we know of doing work on U.S. equality of opportunity. Therefore, we very much hope that it raises the funds that are necessary to continue operating, and in plenty of time. However, it seems important to note that its need for more funds - and ability to translate them into more outcomes - is fairly far off.
Revenue and expense growth
(about this metric
): NFP's expenses have grown over time, which indicates the program can continue to expand. In the three last years we have data for (2007–2009), NFP got approximately twice as much in revenues as it spent, i.e. in these 3 years, it got around $25 million more than it spent. This relationship between NFP's revenues and expenses makes us worry that NFP is taking in more than it can productively spend.
(about this metric
): In 2008 NFP NSO had an assets-to-expenses ratio of approximately 2 and in 2009 the ratio was about 2.5.
Expenses by IRS-reported category
(about this metric
): NFP maintains a reasonable "overhead ratio," spending between approximately 73% and 83% of its budget on program expenses in years 2005 to 2009. In 2004, NFP spent much more on "managment and general" than on programs, which we don't think is a problem since this was during a time when NFP was starting up.
According to NFP, the cost to a community/agency is typically $4,500 per family per year served in the NFP program, and ranges from $2,914 to $6,463 per family per year. We don't know how NFP came to the cost figures above and what costs they include to what actors.
- Coalition for Evidence-Based Policy, Nurse-Family Partnership. http://evidencebasedprograms.org/wordpress/?page_id=57 (accessed August 23, 2011). Archived by WebCite® at http://www.webcitation.org/619q9JcHI.
- Eckenrode, John, et al. 2010. Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial. Archives of Pediatric and Adolescent Medicine 164: 9-15.
- GiveWell. The Nurse-Family Partnership program.
- National Registry of Evidence-Based Programs and Practices. Nurse-Family Partnership. http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=88 (accessed November 11, 2010). Archived by WebCite® at http://www.webcitation.org/5uA8OOmAQ.
- Nurse-Family Partnership. Annual report (2007) (PDF).
- Nurse-Family Partnership. Audited financial statements (2008) (PDF).
- Nurse-Family Partnership. Budgets by program department (2005-2008) (PDF).
- Nurse-Family Partnership. Cost-benefit analysis.
- Nurse-Family Partnership. IRS form 990:
- Nurse-Family Partnership. Example implementing agency evaluation report. Our latest information is that this document is classified as confidential by NFP.
- Nurse-Family Partnership. Model elements. http://www.nursefamilypartnership.org/Communities/Model-elements (accessed June 23, 2010). Archived by WebCite® at http://www.webcitation.org/5qhbO6CXY.
- Nurse-Family Partnership. National statistics (2010) (PDF).
- Nurse-Family Partnership. National office program department descriptions and budgets (Actual) (2009) (DOC).
- Nurse-Family Partnership. Program history. http://www.nursefamilypartnership.org/About/Program-history (accessed September 27, 2010). Archived by WebCite® at http://www.webcitation.org/5t386wPZf.
- Nurse-Family Partnership. Summary metrics and financials. NFP has asked us not to publish this document.
- Nurse-Family Partnership. The home visit experience (PDF).
- Nurse-Family Partnership. Theory of change logic model (PDF).
- Nurse-Family Partnership. What we do. http://www.nursefamilypartnership.org/about/what-we-do (accessed June 23, 2010). Archived by WebCite® at http://www.webcitation.org/5qhZz0hIS.
- Olds, David L., et al. 1997. Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association 278: 637-643.
- Stapleton, Michelle. NFP Fund Development Associate. Email to GiveWell, November 16, 2010.
- Stapleton, Michelle. NFP Fund Development Associate. Phone conversation with GiveWell, July 21, 2010.